Inadvertent Intravenous Administration of an Oral Preparation of Ibuprofen: A Case Report

Inadvertent intravenous administration of oral suspension, which is rarely addressed in routine practice, could contribute to potential patient harm. We received an incident report in which a patient had been accidentally administered an oral liquid formulation intravenously. The practice of preparing or dispensing oral liquids in parenteral syringes is the primary cause of this error. Additionally, the cognitive fatigue experienced during multi-tasking by staff personnel leading to a momentary lapse of concentration as well as the attachability of Luer connection of parenteral syringes to the needleless IV lines also contributes to the incidence. The fact is de-emphasized by the healthcare professionals, and therefore we consistently advise the staff to dispense and administer unit doses of oral liquids in oral syringes. Thus, dispensing and administration of commercially available or compounded oral preparations should be carried out in particular cups and oral syringes or other containers suitable for the particular preparation. For ensuring compliance with this practice, the availability of oral syringes in the hospital and those patient areas where liquid doses are orally administered is essential. Oral syringes are not available in Pakistan and nurses routinely use intravenous syringes for administration of oral liquids to avoid spillage of dose, especially in children or non-cooperative patients. The availability of oral syringes in hospitals could help to reduce inadvertent administration error of medicines.